The Prescribing Cascade 3.0: A Case for Recreational Drugs in HIV

In 2020, a case was reported of a 34-year-old HIV-positive man who developed severe iatrogenic Cushing's syndrome after increasing his use of gamma-hydroxybutyric acid (GHB) from occasional to daily, in an attempt to self-medicate for depression, fatigue, and erectile dysfunction. His condition was exacerbated by the misuse of topical betamethasone for psoriasis and the use of anabolic steroids. Despite normal routine hematochemical and thyroid-stimulating hormone levels, his morning serum cortisol and plasma adrenocorticotropic hormone (ACTH) levels were significantly below normal, leading to the diagnosis of iatrogenic Cushing's syndrome. The patient was advised to stop GHB and betamethasone, and his antiretroviral therapy was changed to minimize drug-drug interactions. After discontinuing cortisone, his cortisol and ACTH levels normalized. This case highlights the importance of considering recreational drugs in the prescribing cascade, where self-administered substances can lead to misinterpreted medical conditions and complex drug interactions, especially in HIV patients on antiretroviral therapy. The study emphasizes the need for infectious disease physicians to be aware of the potential for such interactions and to review all possible drug interactions, including those with recreational drugs.